a quality improvement clinical audit of the Journey day service completed as part of MSc Working with Personality Disorder: Extending Expertise and Enhancing Practice Alan Hirons – Occupational Therapy Clinical Specialist Leeds Personality Disorder Services BIGSPD – Leeds 5 th March 2015

- dedicated Occupational Therapy group work programme - focussed on facilitating adaptive goal directed activity: around control and regulation, and identity - commenced 2006, now on 26 th cycle - evaluation and outcomes consistently positive - but, seemingly high ongoing attrition rate of 50% ● overview of Journey quality improvement clinical audit

- a pragmatic response to - Trust rationalisation of services in response to economic environment - Trust identification of quality improvement as main vehicle for achieving efficiency savings - Francis Report recommendations for engagement with quality assurance processes ● why clinical audit? quality improvement clinical audit

● clinical audit methodology - conceptual shift: traditional quality assurance model to quality improvement model quality improvement clinical audit - Measurement of effectiveness against proven standards of high quality - Action taken to bring practice into line with standards - Improvement in quality of care and health outcomes quality improvement clinical audit

- NICE clinical guideline – BPD (2009) - NICE clinical guideline – Service user experience in adult mental health care / Access to care (2011) - Treatment Readiness Model – PD (Tetley et al, 2010; McMurran, 2012) - Local Commissioner requirements ● stage 1 - sources of criteria

-Section 1: Assessment and entry / 13 standards -Section 2: Facilitating attendance / 4 standards -Section 3: Managing endings and transitions / 6 standards ● stage 1 - standards

- x49 ‘referrals’ (from – ) - represents 45% of referrals in written and electronic data collected between to data processed by Trust Clinical Audit Department ● stage 2 - data collection

-Phase 1: Clinical Audit Lead – overview -Phase 2: Reference Group tasked with reflecting and commenting upon data and making recommendations ● stage 2 - data analysis Membership: ex service users CCG Commissioner Journey staff Directorate AHP Lead Trust Clinical Audit Department representative PD Services group programme lead

- n11/16 (69%) of service users completed their programmes - n10/43 (23%) of service users dropped out of assessment process before meeting a Journey staff member ● stage 2 - general findings

● stage 2 - specific findings Impact of procedural factors – ‘basics’ - Lack of clear instruction on assessment form – 61% - Not enough prompts on assessment form – 97% - Record keeping not complete – 75% Impact of contextual factors – ‘wider issues’ - The apparent complexity and ‘busyness’ of the assessment process - Mismatch of expectations around ‘recovery’ processes

-Section 1: Assessment and entry To improve information given to service user and documentation Service leaflet included in assessment appointment letter Assessment summary letter to be placed on electronic recording system Assessment summary letter to be sent to GP Assessment form redesigned -Section 2: Facilitating attendance To improve recording of interactions and improve provision of written information about personality disorder Instruction given to staff team to record all interactions Reference copy of NICE BPD clinical guideline made available ● stage 3 - changes implemented

-Late Journey 25 programme had n7/8 (88%) completion ● stage 4 - re audit

- ‘paranoid schizoid’ position to ‘depressive’ position ● reflections and learning quality improvement clinical audit heightened anxiety sense of isolation sense of ‘defending’ closed system ‘authoritarian’ style reference group engagement with anxiety collective endeavour clarity of primary task open system ‘authoritative’ style

- worthwhile – direct evidenced based information - immediate engagement with quality improvement - organising and focussing of energy and endeavour - invigorating ● overall learning quality improvement clinical audit